Provider Demographics
NPI:1124350731
Name:PARK, ANNE (LAC)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 POWELL ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2600
Mailing Address - Country:US
Mailing Address - Phone:510-597-9923
Mailing Address - Fax:
Practice Address - Street 1:1240 POWELL ST STE 2A
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2600
Practice Address - Country:US
Practice Address - Phone:510-597-9923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-06
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13007171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist